March 20 th, 2018 Public Health Approaches to Addressing Neonatal Abstinence Syndrome
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Presenters Shanna Cox Janine Breyel 3
Disclosure and Disclaimer No financial relationships to disclose. The findings and conclusions in this presentation are those of the presenter and do not necessarily represent the official position of the Centers for Disease Control and Prevention. 4
Centers for Disease Control and Prevention Public Health Approaches to Addressing Neonatal Abstinence Syndrome Shanna Cox, MSPH Associate Director for Science CDC Division of Reproductive Health March 20, 2018 5
Epidemiological Data Opioid use generally and among women of reproductive age Neonatal Abstinence Syndrome (NAS)
Source: New York Times, The Upshot, June 5, 2017: https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-risingfaster-than-ever.html 7
Opioid Overdose ED Visits Continue to Rise From July 2016 September 2017, opioid overdoses increased for: Men (up 30%) and women (up 24%) People age 25 34 (up 31%); 35 54 (up 36%); and 55 and over (up 32%) Most states (up 30% average) esp. in the Midwest (up 70% average) SOURCE: CDC s National Syndromic Surveillance Program, 52 jurisdictions in 45 states reporting.
Frequencies per 1,000 Deliveries Opioid Abuse and Dependence Among Pregnant Women 4.5 4 3.5 3 2.5 2 1.5 1 Opioid abuse or dependence per 1,000 deliveries, overall and by agein the U.S., 1998 2011 0.5 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 StudyYear Source: Maeda et al., Anesthesiology, 2014. 9
Opioid Prescription Use Among Women of Reproductive Age and Pregnant Women According to U.S. estimates: One-third of reproductive-aged women filled a prescription for an opioid medication 14% 22% of women filled an opioid medication prescription during pregnancy Sources: Ailes et al., MMWR, 2015; Bateman et al., Anesthesiology, 2014; Desai et al., Obstet Gynecol., 2014; Maeda et al., Anesthesiology, 2014. 10
Number of ED visits Every 3 minutes, a woman goes to the emergency department for prescription pain reliever misuse or abuse 50,000 40,000 30,000 20,000 10,000 0 <18 18 24 25 34 35 44 45 54 55 64 65+ Women by age group
Deaths per 100,000 population Opioid-Related Overdose Deaths, U.S., 1999-2015 10 All opioids 8 6 Commonly prescribed opioids 4 2 Heroin and Synthetic opioids like fentanyl 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Source: National Vital Statistics System Mortality File https://www.cdc.gov/nchs/products/databriefs/db273.htm. 12
Neonatal Abstinence Syndrome (NAS) Drug withdrawal syndrome in newborns with fetal exposure to substances Opioid exposure: prescription pain relievers, illicit substances, opioid maintenance therapy Withdrawal symptoms most commonly occur 48 72 hours after birth Tremors, hyperactive reflexes, seizures Excessive or high-pitched crying, irritability, yawning, stuffy nose, sneezing, sleep disturbances Poor feeding and sucking, vomiting, loose stools, dehydration, poor weight gain Increased sweating, temperature instability, fever Source: Hudak et al., Pediatrics, 2012. 13
NAS on the Rise 2,920 infants with NAS in 2000 21,732 infants with NAS in 2012 1.2 In 2012, one infant with NAS was born every 25 minutes Sources: Patrick et al., JAMA, 2012; Patrick et al., J Perinatol., 2015. 14
NAS Incidence By Geographic Region, 2012 Source: Patrick et al., J Perinatol., 2015. 15
Incidence of NAS, 25 States, 2012 2013 Incidence rates per 1,000 hospital births Source: Ko et al., MMWR Morb Mortal Wkly Rep, 2016. 16
Infants with NAS: Treatment and Costs Exposed infants can require pharmacologic treatment (morphine, methadone, phenobarbital, etc.) 30%, 68%, 91% of NAS infants required pharmacologic treatment in separate studies Mean length of stay: 23 days Mean hospital charge: $93,400 per infant Total cost: $1.5 billion Medicaid is the most common payer ($1.2 billion) Sources: Ebner et al., Drug Alcohol Depend., 2007; Greig et al., Arch Gynecol Obstet., 2012.; Kuschel. Semin Fetal Neonatal Med., 2007.; Patrick et al., J Perinatol., 2015.; Strauss et al., Am J Obstet Gynecol., 1974. 17
What is CDC Doing to Reduce the Opioid Epidemic and NAS?
Public Health Strategies to Address NAS Source: Ko et al., MMWR Morb Mortal Wkly Rep, 2016. 19
Public Health Strategies to Address NAS Preconception During Pregnancy Birth and Neonatal Period Infancy and Childhood Prevention of opioid abuse and dependence Appropriate prescribing Prescription drug monitoring programs Decrease unintended pregnancies among women who abuse opioids Preconception health care Quality family planning services Source: Ko et al., MMWR Morb Mortal Wkly Rep, 2016. 20
Opioids Prescribed Per Person, 2015 Source: CDC Vital Signs, July 2017: https://www.cdc.gov/vitalsigns/opioids/index.html 21
Three Pillars of CDC s Work to Reverse the Prescription Drug Overdose Epidemic Improve data quality and track trends Strengthen state efforts by scaling up effective public health interventions Supply healthcare providers with resources to improve patient safety
Tackling the Opioid Epidemic: Prevention Efforts at CDC Prescribing Guideline Data to Drive Action Prescription Drug Monitoring Program See patterns of misuse Source: Vital Signs, March, 2018 Goal: Integrated into electronic health systems and linked directly to coroner and medical examiners
CDC Recommendations for Providers for Preconception and Pregnant Women Reproductive-aged women discuss family planning and how long-term opioiduse might affect any future pregnancy Pregnant women Carefully weigh risks and benefits when making decisions about whether to initiate opioid therapy Pregnant women with opioid use disorder medication-assisted therapy with buprenorphine (without naloxone) or methadone has been associated with improved maternal outcomes and should be offered Source: Dowell et al., MMWR Recomm Rep., 2016. 24
Prescription Drug Monitoring Programs (PDMPs) State-based databases (N=49)* of controlled prescription drugs dispensed by pharmacies Contain critical clinical data that can help: - Identify patients at risk for opioid-related overdoses and struggling with opioid use disorder - On high total doses, receiving from multiple sources - Inform providers of other medications the patient is receiving that may interact with those prescribed Studies have shown reduction in opioid-related overdose and deaths in the general population *Missouri does not have a PDMP Source: CDC National Center for Injury Prevention and Control: pdmpexcellence.org/sites/all/pdfs/coe_briefing_mandates_2nd_rev.pdf 25
Improving Preconception Health Nearly 50% of all pregnancies in the U.S. are unintended 86% of pregnancies among women who abuse opioids are unintended Achieve optimal health and wellness fostering a healthy life course for them and any children they may have Increase access to effective contraception among women who do not intend to become pregnant Sources: Finer and Zolna, N Engl J Med., 2016;Heil et al., J Subst Abuse Treat., 2011. 26
Examples in Action CHOICES and fetal alcohol syndrome At 9 month follow-up evaluation, 69% of women in CHOICES intervention reported reducing risk of alcohol-exposed pregnancies vs. 54% of women in usual care Partnerships to provide education and family planning services to nontraditional sites (TN, WV) Reach women with substance abuse in drug court, upon release from incarceration, during needle exchanges, and at maternal addiction recovery centers Sources: https://www.cdc.gov/ncbddd/fasd/documents/choices_onepager_-april2013.pdf; http://www.astho.org/maternal-and-child-health/increasing-access-to- Contraception/Learning-Community/Slides-Dec-20-2016/ 27
Challenges to primary prevention of NAS High prescribing and uptake of 2016 clinical guidelines Amount of opioids prescribed in 2015 remained approximately three times as high as in 1999 PDMPs are not widely adopted Provider time constraints, lack of data integration into electronic medical records Preconception health and family planning Logistical challenges, patient preference, myths, providers not trained, partial reimbursement Sources: Patrick et al., Health Aff 2016; Tyler et al., Obstet Gynecol. 2012; Madden et al., Contraception. 2010; Holland et al., Womens Health Issues. 2015 28
Public Health Strategies to Address NAS Preconception During Pregnancy Birth and Neonatal Period Infancy and Childhood Universal screening for substance use Access to treatment Evaluation of maternal concurrent substance use and comorbidities Source: Ko et al., MMWR Morb Mortal Wkly Rep, 2016. 29
American College of Obstetricians and Gynecologists (ACOG) Recommendations Early screening, brief intervention, and referral for treatment (SBIRT) improves maternal and infant outcomes Screening is part of comprehensive obstetric care and should be done at the first prenatal visit in partnership with pregnant woman Essential that it is universal Use validated screening tools (e.g., 4Ps, NIDA quick screen, CRAFFT for women 26 years or younger) Maintain caring and non-judgmental approach Source: American College of Obstetricians and Gynecologists and American Society of Addiction Medicine, 2017 30
Challenges to Addressing Needs of Pregnant Women Screening Few screening instruments validated for use among pregnant woman Debate on when and how often to screen, whether biological specimens should be used in conjunction Varying state laws and policies Unmet need for referrals and resources Addition of 20,398 waived physicians (30-day or 100-day patient limit) and 100 opioid treatment programs from 2003-2012 Evaluation of maternal concurrent substance use and comorbidities Source: ACOG Committee on Health Care for Underserved Women, American Society of Addiction Medicine. Obstet Gynecol., 2012, Jones et al., AJPH, 2015 31
Public Health Strategies to Address NAS Preconception During Pregnancy Birth and Neonatal Period Infancy and Childhood Collaboration between prenatal care providers and pediatricians Improved identification of infants at-risk for NAS Standardize evidence-based care Source: Ko et al., MMWR Morb Mortal Wkly Rep, 2016. 32
Public Health Strategies to Address NAS Preconception During Pregnancy Birth and Neonatal Period Infancy and Childhood Decrease readmission risk Services for long-term outcomes Safe care plans Source: https://www.congress.gov/bill/114th-congress/senate-bill/524/text 33
Challenges to Addressing Needs of Infants with NAS Limited data on readmission risk Limited evidence on prenatal exposure and long-term developmental outcomes Timing and type of exposure Role of environment and parental comorbidities Need for collaborative and coordinated services for both child and family Source: Reddy et al., Obstet Gynecol, 2017; SAMHSA: https://ncsacw.samhsa.gov/files/collaborative_approach_508.pdf 34
Addressing Needs of Women and Infants Improving surveillance Pregnancy Risk Assessment Monitoring System (PRAMS) substance abuse modules Birth certificate and claims data linkage Maternal Mortality Review Committees Providing technical assistance to state health departments Supporting state perinatal quality collaboratives (PQCs) implementing evidenceinformed treatment protocols to improve outcomes for infants and reduce costs
Take Home Message
Thank you! For more information, contact CDC 1-800-CDC-INFO (232-4636) TTY: 1-888-232-6348 www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. 37
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50% 45% 40% 35% 42.1% 40.4% 41.5% 41.3% 40.4% 40.8% 40.5% 40.7% 40.4% 38.5% 39.5% 39.9% 38.8% 40.3% 42.4% 39.9% 30% 25% 20% 15% 10% 5% 0% WV Average 25% 13.9% 12.3% 12.7% 12.4% 11.7% 10.2% 10.1% 9.6% 13.8% 11.9% 12.9% 11.7% 12.4% 11.6% 9.9% 10.0% Medicaid Non-Medicaid US Rate 7.2% 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016* Preliminary Data Source: West Virginia Health Statistics Center, Vital Statistics System, 2018 * 45
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Source: State Inpatient Databases, Healthcare Cost and Utilization Project * 47
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2 55 73 66 245 330 391 SUBSTANCE USE OF DFMB PARTICIPANTS Number of Participants Abusing This Substance 54
180 Positive Drug Screens 160 140 120 100 80 60 40 20 0 First Trimester Second Trimester Third Trimester At Delivery Number of Participants 55
28 112 295 BIRTH OUTCOME Number of Participants NAS LIVE, TERM BIRTH LIVE, PRETERM BIRTH 56
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COCAINE METH CAFFEINE CIGARETTESCRACK ALCOHOL BENZOS SPEED FENTANYL ICE OXYS LORTAB WEED QUELL POT HEROIN XANAX BOOZE MARIJUANA OXYS E-CIGARETTES CRANK Alcohol, tobacco and drugs can harm your baby and cause serious problems. USING THESE WHILE PREGNANT IS RISKY AND MAY CAUSE YOUR BABY TO: Be born too small or too early Be stillborn or die in infancy Go through withdrawal after birth Have breathing problems Have birth defects This pamphlet is made possible through a generous grant from the Claude Worthington Benedum Foundation and the WV Department of Health and Human Resources, Bureau for Behavioral Health and Health Facilities and Bureau for Public Health, Office of Maternal, Child and Family Health. W O R K I N G TOGETHER FOR HEALTHIER MOTHERS AND BABIES. Information provided by: With the supportof: A healthier future is IN YOUR HANDS and within your reach With your courage and the support and compassionate care of your health care providers, a better future is possible. Have learning, behavioral or other health problems throughout life Drugs and Pregnancy 60
I M AFRAID FOR OTHERS TO KNOW I AM USING SUBSTANCE USE IN PREGNANCY It is understandable that you may be afraid to talk about your drug use, but your doctor needs to know so that you and your baby receive the best care possible. They can help arrange treatment and make sure you have the best care for you and your baby. Mothers who seek treatment during pregnancy receive the support they need and are less likely to have custody issues after birth. Almost every substance you take when pregnant can pass into your baby. This means that the baby shares the caffeine, alcohol, drugs, nicotine, medications and other substances you take while you are pregnant. Your baby may go through withdrawal once he or she is born. This is called Neonatal Abstinence Syndrome (NAS) or neonatal withdrawal. PRENATAL CARE If you are pregnant, it is important that you see a doctor or midwife as soon as possible, and keep all of your prenatal appointments. Talk openly with your doctor or midwife about any drugs or medications you are taking or have taken in the past. Any changes in your medications or drug habits can affect you and your baby s health. Weaning from certain drugs (whether prescribed or off the street) may be dangerous. Do NOT attempt to rapidly wean yourself at any time, including just prior to delivery. This can cause serious health problems for you and your baby. If you are in a treatment program and receiving medication assisted treatment (MAT), such as methadone or Subutex/Suboxone (buprenorphine), be sure to tell your doctor. You should sign a release of information so your doctor can access your treatment records. It is important that information about your health and pregnancy be shared with those caring for you and your baby. It is important you stay in treatment and continue to take your medication as prescribed. SUPPORT AND ASSISTANCE FOR YOU AND YOUR FAMILY It is recommended that you participate in a home visitation program for support, for help linking to needed resources, and for follow up care for your baby. More information about home visitation services can be found at: https://www.homevisitwv.org/ GET THE SUPPORT YOU NEED If you or someone you know needs help with substance abuse, CALL 61
SAFE SLEEP Smoking during pregnancy, using alcohol and drugs during pregnancy, and exposure to second and third hand smoke increase your baby s risk for Sudden Infant Death Syndrome and Sudden Unexpected Infant Death (SIDS/ SUID). Babies should always sleep in rooms and homes that are smoke-free. Toys, heavy or loose blankets, bumper pads and pillows can cause suffocation and should be removed from your baby s crib, bassinet, or pack and play. ONCE YOUR BABY GOES HOME Your baby needs the same calm, gentle care at home as he or she had in the hospital. It is important for your baby to have a regular routine. Try to keep your baby s surroundings quiet and soothing. Your baby may continue to show some signs of withdrawal, such as crying and being fussy after leaving the hospital. Dealing with a fussy baby can be overwhelming and frustrating. Let people you trust help you. It is very important to follow the ABC s of infant safe sleep Alone Your baby should always sleep alone, but nearby. Your baby should never sleep in a bed with an adult or other child. B a c k Always place your baby on his back to sleep for every bedtime and nap time. C rib Babies should only sleep in a safety approved crib, bassinet, or pack-n-play, and not on a couch, adult bed, chair or recliner. If you or someone you know needs help with substance abuse, call: This pamphlet is made possible through a generous grant from the Claude Worthington Benedum Foundation and the WV Department of Health and Human Resources, Bureau for Behavioral Health and Health Facilities and Bureau for Public Health, Office of Maternal, Child and Family Health. W O R K I N G TOGETHER FOR HEALTHIER MOTHERS AND BABIES. Information provided by: With the supportof: A healthier future is IN YOUR HANDS and within reach With your courage and the support and compassionate care of your health care providers, a better future is possible. Caring for Babies Affected by Drug Exposure 62
SUBSTANCE USE IN PREGNANCY WHAT TO EXPECT WHEN YOUR BABY IS BORN HOW CAN YOU HELP YOUR BABY? Almost every substance you take when pregnant can pass into your baby. This means that the baby shares the caffeine, alcohol, drugs, nicotine, medications and other substances you take while you are pregnant. Your baby may go through withdrawal once he or she is born. This is called Neonatal Abstinence Syndrome (NAS) or neonatal withdrawal. UNDERSTANDING NAS (Neonatal Abstinence Syndrome) Some substances contain addictive qualities, and just like you, your unborn baby may become dependent upon the substance(s) you are using. Your baby may go through withdrawal once he or she is born and no longer receiving those substances from you. This is called Neonatal Abstinence Syndrome (NAS), or neonatal withdrawal. There is no way to know if your baby will go through withdrawal or how bad it will be. The use of more than one drug (known as poly-substance or polydrug use) can make withdrawal worse for the baby, especially when mothers also smoke or use nicotine products. Babies whose mothers used certain drugs while pregnant, (whether the drug is a prescription or not) may be kept at the hospital for at least 3-5 days after birth to watch for symptoms of withdrawal. Nurses will measure your baby s symptoms using a scoring system. Your baby s score helps the doctor and nurses decide if your baby needs medication. Most babies who require medication to control withdrawal symptoms need to stay in the hospital 2-4 weeks, but some may need to stay longer. Your baby s medication will gradually be reduced. This process is called weaning. It can take several weeks or longer to fully wean your baby. YOUR BABY S SYMPTOMS MAY APPEAR on average at as late as 72 HOURS 4 WEEKS and include: trembling or shaking, even when sleeping a stuffy nose loose watery stools feeding poorly weak suck, spitting up sensitivity to light, sounds and touch sweating fussiness trouble sleeping crying a lot yawning a lot sneezing a lot Your love and care are most important to your baby. During your baby s stay at the hospital, plan to spend as much time as possible with your baby. The nursing staff will help you learn special ways to handle your baby. BE GENTLE, BE QUIET, AND BE CALM. Quiet Keep your baby s surroundings quiet and calm. Use a soft voice. Keep visitors to a minimum. Calm Keep the lights low. Breastfeeding is encouraged if recommended by your pediatrician. Let your baby sleep. Only wake him or her for feeding. Let your baby suck on a pacifier. Gentle Care for your baby without handling him or her too much. Gently and slowly rub or pat your baby s back. Touch and move your baby gently and slowly. Do not overdress your baby or add too many blankets. Hold your baby: (1) Skin to Skin (2) With baby s arms close to his or her chest (3) Upright rocking your baby with smooth, slow, upward-anddown movements Swaddle your baby when he or she is not skin-to-skin. 63
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* Birth Score is part of WV Project WATCH, a program of the WV Office of Maternal, Child and Family Health. 70
Source: Using a current surveillance tool to assess the incidence of neonatal abstinence syndrome (NAS) in West Virginia, John, Collin, et al Poster Presentation at 2017 APHA conference 71
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